The Final Ockenden Report

At the start of the review there were 23 cases of concern but this number grew to include reviews of the maternity care for nearly 1,500 families, whose experiences occurred predominantly between 2000 and 2019. The review included some families who had experienced multiple clinical incidents.

As the summary findings, conclusions and essential actions of the review make clear, the priority was to ensure that the families impacted by the maternity services at the Trust were heard, were able to understand what had happened and to ensure that lessons are learned to avoid further families experiencing the same harm and distress. In addition, the review also crucially wanted to ensure that staff had an opportunity to be heard.

The initial report and the final report set out Local Actions for Learning (LAfLs) and Immediate and Essential Actions (IEAs) to be implemented at the Trust and across the wider maternity system in England.

Some of the LAfLs, IEAs and the focus areas outlined in the Ockenden Report are currently incentivised as part of NHS Resolution’s Maternity Incentive Scheme Year 4.  Those included are: safety action 4 (medical workforce), safety action 5 (midwifery staffing), safety action 6 (Saving Babies Lives care bundle), safety action 7 (Maternity Voices Partnership), safety action 8 (training), and safety action 9 (safety champions).

Findings

In summary the review found that the working practices and attitudes within the maternity service and the maternity governance team at the Trust did not pay sufficient attention to the safety of mothers and babies.

Looking at the management and how investigations were handled within the maternity services at the Trust, the key themes requiring improvement were:

• The poor quality of incident investigations;
• Poor complaints handling;
• Local concerns with statutory supervision of midwifery investigations;
• Concerns with clinical guidelines and clinical audit;
• Poor clinical leadership.

The above issues led to a lack of learning, missed opportunities to improve safety and did not provide families with honest and open responses.

In addition, and in consideration of the specific cases under investigation, the review looked at six areas of care:

• Antenatal care
• Intrapartum care
• Postnatal care
• Maternal deaths
• Obstetric anaesthesia
• Neonatal care

Whilst the review showed some aspects of good care in each area, it also found a a significant amount of poor care. Issues related to, amongst other things, delay in treatment, misdiagnosis, lack of senior review, lack of escalation and misinterpretation of CTGs.

The above findings led to 64 specific Local Actions for Learning (LAfLs) which are set are out in the final report. Whilst these are primarily directed at the Shrewsbury and Telford Hospital NHS Trust they will no doubt be reviewed by all Trusts across England and their application to an individual Trust’s maternity service considered.

Local Actions for Learnings (LAfLs)

The LAfLs fall under a number of separate headings, and a summary of these are set out below:

Clinical Governance

• Improving Management Of Patient Safety Incidents

Incidents must be graded appropriately, with the level of harm recorded as the level of harm the patient actually suffered and in line with the relevant incident framework.

• Patient And Family Involvement

The needs of those affected must be the primary concern during incident investigations. Patients and their families must be actively involved throughout the investigation process.

• Support For Staff

There must be a robust process in place to ensure that all safety concerns raised by staff are investigated, with feedback given to the person raising the concern.

• Improving Complaints Handling

Complaint responses should be empathetic and kind in their nature. The local MVP must be involved in helping design and implement a complaints response template which is relevant and appropriate for maternity services.

• Improving Audit Process

There must be midwifery and obstetric co-leads for audits.

• Improving Guidelines Process

There must be midwifery and obstetric co-leads for developing guidelines.

• Leadership And Oversight

The Trust Board must review the progress of the maternity improvement and transformation plan every month.

Antenatal Care

• Care Of Vulnerable And High Risk Women

The Trust must adopt a consistent and systematic approach to risk assessment at booking and throughout pregnancy to ensure women are supported effectively and referred to specialist services where required.

• Fetal Growth Assessment And Management

The Trust must have robust local guidance in place for the assessment of fetal growth. There must be training in symphysis fundal height (SFH) measurements and audit of the documentation of it, at least annually.

• Fetal Medicine Care

The Trust must ensure parents receive appropriate information in all cases of fetal abnormality, including involvement of the wider multidisciplinary team at the tertiary unit. Consideration must be given for birth in the tertiary centre as the best option in complex cases.

• Diabetes Care

The Trust must develop a robust pregnancy diabetes service that can accommodate timely reviews for women with pre-existing and gestational diabetes in pregnancy. This service must run on a weekly basis and have internal cover to permit staff holidays and study leave.

• Hypertension

Staff working in maternity care at the Trust must be vigilant with regard to management of gestational hypertension in pregnancy. Hospital guidance must be updated to reflect national guidelines in a timely manner particularly when changes occur. Where there is deviation in local guidance from national guidance a comprehensive local risk assessment must be undertaken with the reasons for the deviation documented clearly in the guidance.

• Consultant Obstetric Ward Rounds And Clinical Review

All patients with unplanned acute admissions to the antenatal ward, excluding women in early labour, must have a consultant review within 14 hours of admission (Seven Day Clinical Services NHSE 2017237). These consultant reviews must occur with a clearly documented plan recorded in the maternity records.

• Escalation Of Concerns

The Trust’s escalation policy must be adhered to and highlighted on training days to all maternity staff.

Intrapartum Care

• Multidisciplinary Working

The labour ward coordinator must be the first point of referral and be proactive in role modelling the professional behaviours and personal values that are consistent with positive team working and providing timely support for midwives when asked or when abnormality in labour presents.

• Fetal Assessment And Monitoring

Obstetricians must not assess fetal wellbeing with fetal blood sampling (FBS) in the presence of suspected fetal infection.

• Specific To Midwifery-Led Units And Out-Of-Hospital Births

Midwifery-led units must complete yearly operational risk assessments.

Maternal Deaths

In view of the relatively high number of direct maternal deaths, the Trust’s current mandatory multidisciplinary team training for common obstetric emergencies must be reviewed in partnership with a neighbouring tertiary unit to ensure they are fit for purpose. This outcome of the review and potential action plan for improvement must be monitored by the LMS.

Obstetric Anaesthesia

The Trust’s executive team must urgently address the deficiency in consultant anaesthetic staffing affecting daytime obstetric clinical work. Minimum consultant staffing must be in line with GPAS at all times. It is essential that sufficient consultant appointments are made to ensure adequate consultant cover for absences relating to annual, study and professional leave.  

Neonatal

The Trust must ensure that there is a clearly documented, early consultation with a tertiary NICU for babies who require, or are anticipated to require, continuing intensive care. This must be the subject of regular audit.

Postnatal

The Trust must ensure that a woman’s GP is given complete, accurate and timely, information when a woman experiences a perinatal loss, or any other serious adverse event during pregnancy, birth or postnatal continuum.

Staff Voices

The Trust must address as a matter of urgency the culture concerns highlighted through the staff voices initiative regarding poor staff behaviour and bullying, which remain apparent within the maternity service as illustrated by the results of the 2018 MatNeo culture survey.

Supporting Families After This Review Is Published

Maternity care must be delivered by the Trust recognising that there will be an ongoing legacy of maternity related trauma within the local community, felt through generations of families.

Immediate and Essential Actions (IEAs)

In addition to the LAfLs the final report sets out around 92 Immediate and Essential Actions (IEAs), these fall under 15 sub-headings and a summary of these are set out below.

The IEAs within the final report are intended to expand on those set out in the initial December 2020 report. These IEAs are intended to be for the benefit of all maternity services across England, with the aim of making significant improvements to the quality of care provided to families.

Workforce planning and sustainability and training

This will require significant funding and the Trusts meeting minimum staffing levels.  All Trusts must implement a programme for newly qualified midwives (NQMs), which offers them support from the initial stages with learning and professional development.  

Safe staffing

The aim is to ensure there is a clear pathway for escalating and dealing with staffing issues. Newly appointed Band 7 or 8 midwives must be allocated a named and experienced mentor to support their transition into leadership and management roles.

Escalation and accountability

All Trusts must develop and maintain a conflict of clinical opinion policy to support staff members in being able to escalate their clinical concerns regarding any woman’s care in case of disagreement between healthcare professionals and there must be clear processes for ensuring that obstetric units are staffed by appropriately trained staff at all times.

Clinical governance – leadership

This focuses on ensuring that there is a clear pathway, with designated leaders to escalate concerns, investigate and make changes. Trust boards must work together with maternity departments to develop regular progress and exception reports and assurance reviews, and regularly review the progress of any maternity improvement and transformation plans.

Clinical governance – incident investigation and complaints

Trusts must ensure investigations and complaints are given the utmost importance, and that the responses given to families are transparent, meaningful and honest. Lessons must be learned and implemented.

Learning from maternal deaths

Nationally, all maternal post-mortem examinations must be conducted by a pathologist who is an expert in maternal physiology and pregnancy-related pathologies.

In the case of a maternal death, a joint review panel or investigation of all services involved in the care must include representation from all applicable hospitals or clinical settings and learning from the review must be introduced into clinical practice within 6 months of the completion of the panel.

Multidisciplinary training

The key point here is that staff who work together must train together. Staff must receive regular and up to date training on CTGs and emergency skills.  All Trusts must mandate annual human factor training for all staff working in a maternity setting.

There must be regular multidisciplinary skills drills and on-site training for the management of common obstetric emergencies.

Complex antenatal care

The Trust must follow national guidance and provide services for women with multiple pregnancies, or who have pre-existing conditions which can impact their pregnancies. Local maternity systems, maternal medicine networks and Trusts must ensure that women also have access to pre-conception care.

Preterm birth

Senior clinicians must be involved in counselling women at high risk of very preterm birth, especially when pregnancies that are at the thresholds of viability. Families must be given expert advice on fetal monitoring.

Labour and birth

All women must undergo a full clinical assessment when presenting in early or established labour.  It is mandatory that all women who choose birth outside a hospital setting are provided with accurate and up-to-date written information about the transfer times to the consultant obstetric unit.

Obstetric anaesthesia

Obstetric anaesthesia should be discussed with mothers, with appropriate advice given to avoid incidences of physical and psychological harm.

Postnatal care

All post-natal women should be treated in a timely manner and with sensitivity.

Bereavement care

Trusts must ensure that women who have suffered pregnancy loss have appropriate bereavement care services. It is important that bereaved families receive appropriate and sensitive care, in a timely manner and with follow up.

Neonatal care

There must be clear pathways of care for provision of neonatal care. Neonatal providers must ensure sufficient numbers of appropriately trained consultants, tier 2 staff (middle-grade doctors or advanced neonatal nurse practitioners) and nurses are available in every type of neonatal unit to deliver safe care 24/7 in line with national service specifications.

Supporting families

Care and consideration of the mental health and wellbeing of mothers, their partners and the family as a whole must be integral to all aspects of maternity service provision.

Conclusion

The review acknowledges the important and great work the NHS does as a whole, notwithstanding the challenges it has faced with funding, staffing and in particular the COVID-19 pandemic. However the review has found that there were significant failings within the maternity services at the Shrewsbury and Telford Hospital NHS Trust and it advocates for the changes that need to be made in order to avoid these failings being repeated in future at the Trust and in national maternity services. Implementation of the LAFLs and IEAs, together with provision of the funding that all maternity services in England need, will undoubtedly result in a safer, fairer and more transparent maternity environment that will be welcomed by all stakeholders.

The full final Ockenden report can be found here.